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JBI Database of Systematic Reviews & Implementation Reports 2013;11(12) 94 -108

Physiotherapy to improve gross motor skills in people with intellectual : a systematic review protocol

Judith Hocking1

Alan Pearson2

Julian McNeil3

1. Master of Clinical Science candidate, The Joanna Briggs Institute, The University of Adelaide.

2. Professor of Evidenced Based Healthcare; Executive Director; The Joanna Briggs Institute; Head of School, School of Translational Science; Director, NHMRC Centre of Research Excellence in the Synthesis and Translation of Evidence for the Management and Treatment of Chronic Disease in Indigenous Populations, Faculty of Health Sciences, The University of Adelaide.

3. Rhumatologist, Discipline of , Modbury Campus , The University of Adelaide

Corresponding author

Judith Hocking

[email protected]

Review question/objective

The objective of this systematic review is to identify the best available evidence regarding the effectiveness of physiotherapy interventions in improving gross motor skills in people with an .

More specifically, the objectives are to identify:

• The best available evidence regarding the types of physical interventions used to improve gross motor skills in people with an intellectual disability.

• The best available evidence regarding the effectiveness of on improving gross motor function in people with an intellectual disability.

Background

Physiotherapy (PT) assists in the attainment and retention of improved physical function to better enable a person to undertake their daily activities and participatory roles. PT outcomes can be achieved through alterations in physiological and learning processes involving the cardio-respiratory, musculoskeletal and neurological systems. PT treatment interventions include but are not limited to muscle and rehabilitation,1,2 strengthening3 and ,4 training of specific skills,5 ,6 gait education, helping to decrease the risk of falls and improving strategies.7

Commonly, PT works to assist an individual to improve their level of gross motor skills (GMS).8 GMS are skills that every person attains during their physical development. The GMS commonly attained are rolling, sitting, standing, , running and ball skills. Usually, most GMS are attained during the first

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five years of life. Pervading intellectual disability (ID) with and without physical debility can impede the attainment of GMS, resulting in increased need for carer support with daily activities, decreased independence, a greater likelihood for and other health issues related to a relative lack of movement. Improvement in GMS may be possible irrespective of a client’s baseline level of GMS.

A client’s level of GMS can be accurately assessed and re-assessed in the clinical setting using recognized outcome measurement tools,9,10 including tools specifically for GMS11 and balance.12 Additionally, usual clinical assessment of a client, including subjective/interview and observational/objective assessment processes, and appraisal of the client’s engagement in general physical activity such as and recreation, also help to determine an individual client’s GMS level. Any deficit in GMS may be due to a combination of biomedical and psychosocial reasons; accordingly, there exists a challenge for the health practitioner to carefully assess the client’s needs to ensure accurate clinical deductions are made,13 including liaising with multi-disciplinary team members to ensure the best possible clinical outcomes.

Intellectual disability (ID), or intellectual ,14 is diagnosed when a person has significant impairment in mental functioning and limitations in adaptive behavior, with onset occurring in the person’s developmental years.15,16 Causes for ID can be varied, including but not limited to genetic reasons, various syndromes and CNS insult or disease. Not infrequently, a cause for the ID cannot be identified.17 ID can affect a person in varying ways: skill sets of communication and learning ability are commonly impaired.18,19 Additionally, people with ID suffer a poorer quality of life (QOL), increased morbidity, a higher frequency of mental health issues,20 social vulnerability21 and poor self- efficacy and esteem.22,23 Decreased access to mainstream services24,25 and therapy interventions can compound the impact of the ID, further inhibiting the person's ability to cope with and to the demands of daily living.26 More focused planning on the delivery of health services to people with an ID in order to overcome these potential risks is warranted.

GMS in people with ID can range from a level of normal functioning, through to profound . When a person with ID has GMS impairment, one result is increased difficulty accessing learning opportunities. Consequently, the impact of impairments related to their GMS and also to the ID itself are less likely to be overcome or moderated. This may result in increased functional dependence and poorer health status. There is apparent clinical relevance and need to systematically identify effective ways of providing PT for improving GMS in people with ID.27 There is some evidence to suggest that an integrated physical activity experience can improve adaptive skills for people with an intellectual disability.28 Regardless of the level of baseline functioning, PT may be able to influence GMS and therefore positively influence the level of independence, health status and QOL of the patient.

When assisting people with , PT can be provided as a stand-alone clinical intervention, or as part of a clinical multi-disciplinary team context, alongside , , psychology, , and medical staff; and both intra- and inter- disciplinary.29

To date, no systematic study has been identified that appraises physiotherapy interventions used to improve gross motor skills in people with an ID. The initial search looking for existing systematic reviews and systematic review protocols was conducted by the author during mid-2013. Key search terms utilized for this initial search included physiotherapy, physical therapy, intellectual disability, intellectual developmental disability, mental retardation, gross motor +/- skills, humans. The databases searched were The Joanna Briggs Institute Library, PEDro and the Cochrane Library. Additionally, PubMed was

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searched in the same timeframe looking for literature on PT to assist with improved GMS in people with an ID and no reviews were identified within this search. It is therefore warranted to systematically review the existing literature reporting on PT interventions (in isolation and in association/as part of a multi-disciplinary team treatment) to improve gross motor skills in people with ID. Examples of systematic reviews about topics related to, but not specifically addressing this review’s focus, were identified.30,31

Much research and development has been invested to develop early intervention programs for children with disabilities, aged around 0-5 years old.32-34 There is a considerable history of early intervention as a health focus;35 it affords medical practitioner oversight.34 These programs are now widely recognized and implemented: there is evidence to support intensive PT input,36 careful screening of developmental delay,37 and the use of outcome measurement tools.38 There is comparatively less literature reporting on habilitative programs for persons aged six years and older and particularly for the adult and older adult with ID. It is therefore of worth to systematically review the available literature for persons aged six years and over with ID, in order to identify the best evidence to support PT practice for this population. Additionally, there is indication of benefit in researching across the lifespan for clients with ID; there has previously been research application of an ID pediatric pain assessment tool to develop a related adult ID assessment tool.39 A similar approach may also be applicable in the review field of PT for improvement in people with ID.

People with ID can experience positive physical benefits from exercise therapy interventions, such as increased muscle strength.40,41 Improvement in strength can facilitate gains in GMS and functional independence. However, because many people with ID experience difficulty accessing and/or engaging with mainstream PT, it appears that modified or alternative clinical PT paradigms may be relevant to this area of PT; including the following:

- There may be indication for specific approaches of communication and client engagement to be incorporated into therapy.41

- There may be specific areas requiring greater clinical attention that are unique to some people with ID, such as deeper proprioceptive sensation for improving static balance in patients with .42

- It may be that specific patterns of neuro-physiological impairments require investigation, so that newer models of physical therapy can be used successfully and that the application of usual models of PT does not achieve any useful improvement in diagnostic groups of ID, as is the case at least for some sub-populations of people with ID.43

- More novel modes of intervention, which are not considered as main-stream PT, but with which PT can work alongside, such as hippotherapy, have been used successfully to improve motor function.44

- Improved engagement could be advanced with creative group therapy approaches which optimize peer modelling.45

- An improvement in important clinical indicators such as moving from a sedentary to a non-sedentary lifestyle behavior, can be achieved by targeting a gross motor skill with seemingly only limited direct impact.46

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Keywords intellectual disability; gross motor skill; physiotherapy

Inclusion criteria Types of participants

This review will consider studies that include people (children aged six years and over and adults of all ages) with intellectual disability (mild through to profound), with and without physical disability (mild through to profound).

For the purposes of this systematic review, intellectual disability (ID) refers to a person having impaired academic ability and decreased adaptive behavior, academic skills and learning, with the onset of the ID occurring during the developmental years.14,47

For the purposes of this systematic review, gross motor skill deficits resulting in physical disability will be defined as a person having physical limitations assessed using recognized outcome measurement tools, resulting in impaired movement and function due to biomedical and/or psychosocial causes, as outlined in the World Health Organization International Classification of Functioning, Disability and Health framework.48 Types of intervention(s)/phenomena of interest

This review will consider studies that evaluate any physiotherapy interventions designed to improve gross motor function including, but not limited to: aquatic therapy, , task-specific practice, group programs, individual sessions, peer-facilitated contexts. The review will include interventions/treatments provided by a registered physiotherapist working either as a sole professional, or within a multi-disciplinary context and providing direct or supervised physiotherapy interventions. Settings for interventions can be any usual clinical setting including the client’s home, residential facilities and hospital outpatient departments.

For the purposes of this systematic review, a registered physiotherapist refers to an individual who has successfully completed a recognized tertiary qualification, enabling formal professional registration as a physiotherapist with an accredited registering body. PT is a nationally controlled profession and as such there are different registration requirements for PTs in each nation that has the profession of PT practicing within it. This systematic review will accept on face value the statement within study reports that the intervention was provided by a physiotherapist.

Types of comparators: No-physiotherapy interventions and/or general physical activity programs led by professionals other than PTs (for example school teachers or exercise physiologists). Types of outcomes

Primary outcomes:

• Level of attainment of gross motor skills such as balance and gait, measured using validated measurement instruments. Where possible, these instruments will be assessed in terms of their reliability and validity for the specific cohort.

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Secondary outcomes:

• Engagement in physical activity (freedom in physical activity is directly related to GMS proficiency; improving physical activity results in improved health),49 which can be measured in different ways, including level of endurance50 and time spent in non-sedentary activity.46 Types of studies

This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies and case control studies.

This review will also consider descriptive epidemiological study designs, including case series and individual case reports.

Systematic reviews of topics related to that of the present review will also be considered for the purpose of hand-searching their reference lists in order to identify relevant primary research articles to be considered for in this review.

Search strategy

The search strategy aims to find published studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed, CINAHL, PEDro, Embase and Scopus will be undertaken, followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published from 2008 onwards will be considered for inclusion in this review in order to optimize the likelihood that the studies reflect the tenets of the 2006 United Nations convention on the rights of people with disabilities, which was assigned formal status as a Human Rights Treaty in 2008;51 it also ensures recent models of physiotherapy practice and theory will be represented in the review’s findings. If there are too few studies identified from within this timeframe, the timeframe will be broadened to also include any relevant studies published between 2001 and 2008. The year 2001 marks the publication of the World Health Organization's initial version of the International Classification of Functioning, Disability and Health; this classification system provides a comprehensive framework for assessing and appraising disability.52

Initial keywords to be used when searching the databases will include:

Children, adolescents, adults, older adults, geriatric, very old adult intellectual disability, intellectual developmental disability, mental retardation, developmental disability, physiotherapy, physical therapy, rehabilitation, multi-disciplinary therapy, habilitation assessment, treatment, intervention, therapy, group, individual exercise, , gross motor +/- skill, function, delay, development

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functional in/dependence developmental milestones balance, falls

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review, using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix V). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data collection

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix VI). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-square test and also explored using subgroup analyses, based on the different study designs included in this review. Whilst conducting the analyses, sub-group analyses will be performed where possible to compare age-groups, level of ID and present comorbidities. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Conflicts of interest

Nil.

Acknowledgements

A/Prof Craig Lockwood, The Joanna Briggs Institute, for assistance in developing the review topic.

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References

1. Yu, J, Park, D, Lee, G. Effect of eccentric strengthening on pain, muscle strength, endurance, and functional fitness factors in male patients with achilles . Am J Phys Med Rehabil. 2013; 92(1): 68-76.

2. Mason, DL, Dickens, VA, Vail, A. Rehabilitation for hamstring injuries. Cochrane Database Syst Rev. 2012; 12: CD004575.

3. Gill, SD, McBurney, H. Does exercise reduce pain and improve physical function before hip or replacement ? A systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2013; 94(1): 164-76.

4. Cipriani, DJ, Terry, ME, Haines, MA, Tabibnia, AP, Lyssanova, O. Effect of stretch frequency and sex on the rate of gain and rate of loss in muscle flexibility during a hamstring-stretching program: a randomized single-blind longitudinal study. J Strength Cond Res. 2012; 26(8): 2119-29.

5. Storvold, GV, Jahnsen, R. Intensive motor skills training program combining group and individual sessions for children with . Pediatr Phys Ther. 2010; 22(2): 150-9.

6. Kargarfard, M, Etemadifar, M, Baker, P, Mehrabi, M, Hayatbakhsh, R. Effect of aquatic exercise training on fatigue and health-related quality of life in patients with . Arch Phys Med Rehabil. 2012; 93(10): 1701-8.

7. Wesson, J, Clemson, L, Brodaty, H, Lord, S, Taylor, M, Gitlin, L, Close, J. A feasibility study and pilot randomised trial of a tailored prevention program to reduce falls in older people with mild dementia. BMC Geriatr. 2013; 13(1): 89.

8. Fatudimu, MB. Influence of the environment on performance of gross motor function in children with cerebral palsy. J Pediatr Rehabil Med. 2012; 5(3): 181-6.

9. De Kegel, A, Dhooge, I, Peersman, W, Rijckaert, J, Baetens, T, Cambier, D, Van Waelvelde, H. Construct validity of the assessment of balance in children who are developing typically and in children with hearing impairments. Phys Ther. 2010; 90(12): 1783-94.

10. Adair, B, Said, C. M, Rodda, J, Morris, ME. Psychometric properties of functional mobility tools in hereditary spastic paraplegia and other childhood neurological conditions. Dev Med Child Neurol. 2012; 54(7): 596-605.

11. Sorsdahl, AB, Moe-Nilssen, R, Strand, LI. Observer reliability of the Gross Motor Performance Measure and the Quality of Upper Extremity Skills Test, based on video recordings. Dev Med Child Neurol. 2008; 50(2): 146-51.

12. Downs, S, Marquez, J, Chiarelli, P. The Berg Balance Scale has high intra- and inter-rater reliability but absolute reliability varies across the scale: a systematic review. J Physiother. 2013; 59(2): 93-9.

13. Ring, D. Commentary: the World Health Organization's International Classification of Functioning, Disability, and Health: invaluable framework, questionable research tool. J Hand Surg Am. 2010; 35(11): 1806.

14. Salvador-Carulla L, Reed G M, Vaez-Azizi L M, Cooper S, Martinez-Leal R, Bertell M, Adnams C, Cooray S, Deb S, Akoury-Dirani L, Girimaji S C, Katz G, Kwok H, Luckasson R, Simeonsson R, Walsh

doi: 10.11124/jbisrir-2013-1180 Page 100 JBI Database of Systematic Reviews & Implementation Reports 2013;11(12) 94 -108

C, Munir K, Saxena S. Intellectual developmental disorders: towards a new name, definition and framework for "mental retardation/ intellectual disability" in ICD-11. World . 2011; 10: 175-189.

15. Obi, O, Van Naarden Braun, K., Baio, J, Drews-Botsch, C, Devine, O, Yeargin-Allsopp, M. Effect of incorporating adaptive functioning scores on the prevalence of intellectual disability. Am J Intellect Dev Disabil. 2011; 116(5): 360-70.

16. Navas, P, Verdugo, MA, Arias, B, Gomez, L. E. Development of an instrument for diagnosing significant limitations in adaptive behavior in early childhood. Res Dev Disabil. 2012; 33(5): 1551-9.

17. Schalock, RL. The evolving understanding of the construct of intellectual disability. J Intellect Dev Disabil. 2011; 36(4): 223-33.

18. Bussy, G, Charrin, E, Brun, A, Curie, A, des Portes, V. Implicit procedural learning in fragile X and Down syndrome. J Intellect Disabil Res. 2011; 55(5): 521-8.

19. Fisher, Z, Bailey, R, Willner, P. Practical aspects of a visual aid to decision making. J Intellect Disabil Res. 2012; 56(6): 588-99.

20. Bigby, C. Social inclusion and people with intellectual disability and challenging behaviour: a systematic review. J Intellect Dev Disabil. 2012; 37(4): 360-74.

21. McGrath, L, Jones, R. S., Hastings, R. P. Outcomes of anti-bullying intervention for adults with intellectual disabilities. Res Dev Disabil. 2010; 31(2): 376-80.

22. Ali, A, Hassiotis, A, Strydom, A., King, M. Self stigma in people with intellectual disabilities and courtesy stigma in family carers: a systematic review. Res Dev Disabil. 2012; 33(6): 2122-40.

23. Paterson, L, McKenzie, K, Lindsay, B. Stigma, social comparison and self-esteem in adults with an intellectual disability. J Appl Res Intellect Disabil. 2012; 25(2): 166-76.

24. Bershadsky, J, Taub, S, Engler, J, Moseley, CR, Lakin, KC, Stancliffe, RJ, Larson, S, Ticha, R, Bailey, C, Bradley, V. Place of residence and preventive health care for intellectual and developmental disabilities services recipients in 20 states. Public Health Rep. 2012; 127(5): 475-85.

25. Friedman, SL, Helm, DT, Woodman, AC. Unique and universal barriers: care for aging adults with intellectual disability. Am J Intellect Dev Disabil. 2012; 117(6): 509-32.

26. Belva, BC, Matson, JL. An examination of specific daily living skills deficits in adults with profound intellectual disabilities. Res Dev Disabil. 2013; 34(1): 596-604.

27. Downs, J, Leonard, H, Hill, K. Initial assessment of the StepWatch Activity Monitor to measure walking activity in . Disabil Rehabil. 2012; 34(12): 1010-5.

28. Duvdevany, I. Self-concept and adaptive behaviour of people with intellectual disability in integrated and segregated recreation activities. J Intellect Disabil Res. 2002; 46(Pt 5): 419-29.

29. Zanca, JM, Dijkers, MP, Hsieh, CH, Heinemann, AW, Horn, SD, Smout, RJ, Backus, D. Group therapy utilization in inpatient rehabilitation. Arch Phys Med Rehabil. 2013; 94(4 Suppl): S145-53.

30. Damiano, DL, DeJong, SL. A systematic review of the effectiveness of treadmill training and body

doi: 10.11124/jbisrir-2013-1180 Page 101

JBI Database of Systematic Reviews & Implementation Reports 2013;11(12) 94 -108

weight support in pediatric rehabilitation. J Neurol Phys Ther. 2009; 33(1): 27-44.

31. Dodd, KJ, Shields, N. A systematic review of the outcomes of cardiovascular exercise programs for people with Down syndrome. Arch Phys Med Rehabil. 2005; 86(10): 2051-8.

32. Bhat, AN, Galloway, JC, Landa, RJ. Relation between early motor delay and later communication delay in infants at risk for autism. Infant Behav Dev. 2012; 35(4): 838-46.

33. Scherzer, AL, Chhagan, M, Kauchali, S, Susser, E. Global perspective on early diagnosis and intervention for children with developmental delays and disabilities. Dev Med Child Neurol. 2012; 54(12): 1079-84.

34. Oberklaid, F, Efron, D. Developmental delay--identification and management. Aust Fam . 2005; 34(9): 739-42.

35. Katcher, AL, Haber, JS. The pediatrician and early intervention for the developmentally disabled or handicapped child. Pediatr Rev. 1991; 12(10): 305-12.

36. Christy, JB, Chapman, CG, Murphy, P. The effect of intense physical therapy for children with cerebral palsy. J Pediatr Rehabil Med. 2012; 5(3): 159-70.

37. Grissom, M. Disorders of childhood growth and development: screening and evaluation of the child who misses developmental milestones. FP Essent. 2013; 410: 32-44; quiz 45-50.

38. Eigsti, HJ, Chandler, L, Robinson, C, Bodkin, AW. A longitudinal study of outcome measures for children receiving early intervention services. Pediatr Phys Ther. 2010; 22(3): 304-13.

39. Lotan M, Ljunggren EA, Johnsen TB, Defrin R, Pick CG, Strand LI. A modified version of the non-communicating children pain checklist-revised, adapted to adults with intellectual and developmental disabilities: sensitivity to pain and internal consistency. The Journal of Pain; official journal of the American Pain Society. 2009; 10(4): 398-407.

40. Cowley PM, Ploutz-Snyder LL, Baynard T, Heffernan KS, Jae SY, Hsu S, Lee M, Pitetti KH, Reiman MP, Fernhall B. The effect of progressive resistance training on leg strength, aerobic capacity and functional tasks of daily living in persons with Down syndrome. Disabil Rehabil. 2011; 33(23-24): 2229-36.

41. Mendonca GV, Pereira FD, Fernhall B. Effects of combined aerobic and resistance exercise training in adults with and without Down syndrome. Arch Phys Med Rehabil. 2011; 92(1):37-45.

42. Jankowicz-Szymanska A, Mikolajczyk E, Wojtanowski W. The effect of physical training on static balance in young people with intellectual disability. Research in Developmental Disabilities. 2012; 33(2): 675-81.

43. Capodaglio P, Cimolin V, Vismara L, Grugni G, Parisio C, Sibilia O, Galli M. Postural adaptations to long-term training in Prader-Willi patients. Journal of Neuroengineering and Rehabilitation. 2011; 8: 26.

44. Giagazoglou, P, Arabatzi, F, Dipla, K, Liga, M., Kellis, E. Effect of a hippotherapy intervention program on static balance and strength in adolescents with intellectual disabilities. Res Dev Disabil. 2012; 33(6): 2265-70.

45. Stanish HI, Temple VA. Efficacy of a peer-guided exercise programme for adolescents with intellectual disability. J Appl Res Intellect Disabil.2012; 25(4): 319-28.

doi: 10.11124/jbisrir-2013-1180 Page 102 JBI Database of Systematic Reviews & Implementation Reports 2013;11(12) 94 -108

46. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with Down syndrome: a randomized trial. Physical Therapy.2011; 91(10): 1463-77.

47. Harris, JC. New terminology for mental retardation in DSM-5 and ICD-11. Curr Opin Psychiatry. 2013; 26(3): 260-2.

48. Jette, AM. Toward a common language for function, disability, and health. Phys Ther. 2006; 86(5): 726-34.

49. Shields, N, Taylor, NF, Fernhall, B. A study protocol of a randomised controlled trial to investigate if a community based strength training programme improves work task performance in young adults with Down syndrome. BMC Pediatr. 2010; 10: 17.

50. Westcott McCoy, S, Yocum, A, Bartlett, D J, Mendoza, J, Jeffries, L, Chiarello, L, Palisano, R J. Development of the Early Activity Scale for Endurance for children with cerebral palsy. Pediatr Phys Ther. 2012; 24(3): 232-40.

51. Stuart, H. United Nations convention on the rights of persons with disabilities: a roadmap for change. Curr Opin Psychiatry. 2012; 25(5): 365-9.

52. Madans, J H, Loeb, M. E., Altman, B. M. Measuring disability and monitoring the UN Convention on the Rights of Persons with Disabilities: the work of the Washington Group on Disability Statistics. BMC Public Health.2011; 11 Suppl 4: S4. Insert page break

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Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message

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Appendix II: Data extraction instruments MAStARI data extraction instrument

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